One of the most dramatic international responses to the Millennium Development Goals launched by then United Nations Secretary Kofi Annan in 2000 has been the global public health community’s response to MDG 6 “To combat AIDS, malaria and other diseases” . For HIV/AIDS it led to President George W. Bush’s launch in 2003 of the President’s Emergency Plan for AIDS Relief (PEPFAR) in order to get people in resource-poor countries on antiretroviral drugs, and also to the ambitious Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), and later to large scale neglected tropical disease programs launched by the United States Agency for International Development (USAID), British Department for International Development (DFID), the World Bank and World Health Organization (WHO) for administering rapid impact packages of anthelminthic drugs, together with azithromycin, in order to target seven of the most common NTDs .
DALYs: number by diseases and 21 regions in 2010 (in thousands) Image Credit: Hotez et al.
I choose the word “dramatic” because of the sheer size and scope of these programs. Since 2000, more than $70 billion of overseas development assistance has been spent for mass drug treatments and other allied health interventions, such as antimalarial bednets, health education, and other health system strengthening measures.
This week two large multi-authored studies were published on studies that aim to measure the global public health progress on MDG 6.
The first is a landmark study by the Global Burden of Disease 2013 researchers led by Dr. Christopher Murray and the Institute for Health Metrics and Evaluation at the University of Washington, Seattle, and supported by the Bill & Melinda Gates Foundation. It provides an important snapshot in 2013 on where we stand with HIV/AIDS and malaria, as well as one additional “other disease,” namely tuberculosis. The study analyzes a massive amount of data and I believe this Lancet publication will be a document that will be discussed for its public health and policy implications for a long-time to come.
Among its key findings are that through widespread use of antiretrovirals and other HIV/AIDS prevention measures, the number of new HIV/AIDS cases has decreased from 2.8 million new infections in 1997 to 1.8 million newly infected annually, with an almost two-thirds drop in the number of new pediatric AIDS cases. The number of global deaths annually from HIV/AIDS has also started to fall from 1.7 million in 2005 to 1.3 million in 2013. Similarly for malaria we have gone from 232 million new malaria cases in 2003 to 165 million in 2013, with a decrease from 1.2 million in 2005 to 855,000 deaths in 2013. In contrast the gains in tuberculosis deaths have been more modest, but also muddled by the sharp rise in HIV-associated TB deaths. Overall, I’m squarely in the Jeffrey Sachs camp on this one – overseas development assistance does indeed make a difference!
A second study published in PLOS Neglected Tropical Diseases does a deeper dive in the GBD Study 2010 with respect to neglected tropical diseases (NTDs). Because integrated control of NTDs through mass drug administration and other measures did not begin until 2006 – and is only getting really ramped up in the last couple of years – it is too soon to say what the long term impacts will be on NTD control and elimination (and in terms of achieving London Declaration 2012 targets), but overall I am optimistic. So far, the greatest declines (75 percent since 1990) have been for human African trypanosomiasis (HAT) – such that an elimination strategy may be feasible for Gambian HAT through case detection and treatment. Another finding is the confirmation that many of the world’s NTDS occur in Asia and elsewhere outside of Africa. At PLOS we have used the term “blue marble health” to address the high rates of diseases of poverty among the poor in wealthy countries. In the coming months we hope to publish studies from the GBD Study 2013 on the NTDs and how they vary by region.
My additional takes on the findings from these two papers are as follows: First, despite the gains through currently available interventions we are still going to need additional control tools before we consider eliminating the infections targeted by MDG 6. I think a new generation of vaccines is going to be required. Second, if we glance at the maps where HIV/AIDS and malaria are highest in Sub-Saharan Africa, they are in geographic regions where parasitic co-infections are also widespread, especially female genital schistosomiasis for HIV/AIDS and hookworm for malaria. I believe that continued gains in the control of HIV/AIDS and malaria will require integrating parasite control into programs such as PEPFAR and GFATM.
The GBD Studies 2010 and 2013 are providing the essential bases for making evidence-based public health and policy decisions. They will continue to inform us for a very long time!
- Hotez PJ (2013) Forgotten People Forgotten Diseases: The Neglected Tropical Diseases and their Impact on Global Health and Development Second Edition, ASM Press